State Board of Elections
506 N Harrington Street
Raleigh, NC 27603
Kimberly Westbrook-Strach Mailing Address
Deputy Director – Campaign Reporting PO Box 27255
Raleigh, NC 27611-7255
Fax: (919) 715-8047
Forgiven Loan Statement
This form is used to report a loan that has been forgiven by the lender. The lender’s signature is required
on this form and it must accompany the next filed report
Name of Lender:
Committee receiving loan:
Date of loan:
Amount of original loan:
*Amount of loan to be forgiven:
I, do not wish to be reimbursed
for the amount of the loan indicated above* and will consider the amount loaned a
contribution to the committee.
I understand and confirm no other parties are responsible for payment of this loan. I
may not forgive a loan for which there is an outstanding balance owed to any source.
Signature of Lender
Signature of Committee Treasurer
Note: This Statement is to be filed with the Election Board where the committee’s reports are filed.
CRO-6200 Forgiven Loan Statement June 2007